DEN05FA034

NTSB accident investigation · Mitsubishi MU-2B-60 · Englewood, CO · December 11, 2004

Accident · FatalField investigationFinal report
Date
December 10, 2004, 19:40 local (Dec 11, 2004, 02:40 UTC)
Place
Englewood, CO
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N538EAMitsubishi MU-2B-60
Weather
Visual (VMC) · Night
Status
Completed · report May 30, 2006
Report
Approved by Office Director
Parties
Flight Line, Inc., Honeywell Engines, Systems and Services, Mitsubishi Heavy Industries America, Inc., FAA Flight Standards District Office, Hartzell Propeller Inc.
FAA report
20041210033119A
Case key
60707

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

the pilot's failure to maintain minimum controllable airspeed during the night visual approach resulting in a loss of control and uncontrolled descent into terrain. A contributing factor was the precautionary shutdown of the left engine for undetermined reasons.

Analysis

Shortly after takeoff, the pilot reported to air traffic control he needed to return to the airport to land. The controller asked the pilot if he required any assistance, and the pilot responded, "negative for right now uh just need to get in as soon as possible." The controller then asked the pilot what the problem was, in which the pilot responded, "stand by one minute." Approximately 30 seconds later and while the airplane was on a left downwind to runway 35R, the pilot stated he was declaring an emergency and "...we've got an air an engine ta shut down uh please roll the equipment." The controller and other witnesses observed the airplane on the base leg and then overshoot the final approach to runway 35R. After observing the airplane overshoot the final approach, the controller then cleared the pilot to the next runway, runway 28, and there was no response from the pilot. The controller observed the airplane's landing lights turn down toward the terrain, and "the MU2 was gone." A witness observed the airplane make an "immediate sharp bank to the left and descend to the ground. The impact appeared to be just less than a 45 degree angle, nose first." A performance study revealed that while the airplane was on downwind, the airplane started to bank to the left. The bank angle indicated a constant left bank angle of about 24 degrees as the airplane turned to base leg. Twenty-three seconds later, the bank angle began to increase further as the airplane turned to final approach, overshooting the runway, while the angle of attack reached stall angle of about 17 degrees. The flight path angle then showed a decrease by 22 to 25 degrees, the calibrated airspeed showed a decrease by 40 to 70 knots, and the vertical speed indicated a 3,000 feet per minute descent rate just before impact. Examination of the airframe revealed the flaps were in the 20 degree position, and the landing gear was retracted. According to the airplane flight manual, during the base leg, the flaps should remain in the 5 degree position and the landing gear extended; and when landing is assured, the flaps then extended to 20 degrees and maintain 125 knots calibrated airspeed (KCAS) during final and 110 KCAS when over the runway. Minimum controllable airspeed (Vmc) for the airplane is 99 KCAS. Examination of the propellers revealed that at the time of impact, the left propeller was in the feathered position and the right propeller was in the normal operating range. Examination of the left engine revealed static witness marks on several internal engine components, and no anomalies were noted that would have precluded normal operation. The reason for the precautionary shutdown of the left engine was not determined. Examination of the right engine revealed rotational scorring and metal spray deposits on several internal engine components. Four vanes of the oil pump transfer tube were separated and missing. The gearbox oil-scavenge pump was not free to rotate and was disassembled. Disassembly of the oil-scavenge pump revealed one separated oil pump transfer tube vane was located in the pump. Pitting and wear damage was noted on all of the roller bearing elements and the outer bearing race of the propeller shaft roller bearing. No additional anomalies were noted.

Factual narrative

The factual narrative1,290 words

History of flight

On December 10, 2004, approximately 1940 mountain standard time, a Mitsubishi MU-2B-60 twin-engine turbo-prop airplane, N538EA, operated as American Check 900 (ACT 900), was destroyed when it impacted terrain following a loss of control while maneuvering near Centennial Airport (APA), Englewood, Colorado. The airplane was registered to and operated by Flight Line, Inc., Watkins, Colorado. Night visual meteorological conditions prevailed at the time of the accident. The unscheduled domestic cargo flight was being operated under the provisions of Title 14 CFR Part 135 under an instrument flight rules flight plan. The airline transport pilot and pilot-rated passenger sustained fatal injuries. The flight departed APA at 1936, and was en route to Salt Lake City International Airport (SLC), Salt Lake City, Utah.

According to Federal Aviation Administration (FAA) Centennial Air Traffic Control Tower (ATCT) transcripts and Denver Air Route Traffic Control Center (ARTCC) radar data, at 1929:27, the local controller cleared ACT 900 to taxi to runway 35R, and the pilot acknowledged the instruction. At 1933:09, the pilot informed the local controller they were ready for takeoff at the end of the runway. At 1935:05, the controller instructed ACT 900 to "full length runway three five right position and hold..." At 1936:04, the controller cleared ACT 900 for takeoff on runway 35R, and the pilot acknowledged the takeoff clearance. At 1936:56, the controller instructed ACT 900 to turn left to a heading of 280 degrees, and the pilot acknowledged the instruction.

At 1937:02, the airplane was approximately 500 feet agl, and the local controller instructed the pilot to contact Denver departure control; the pilot acknowledged the request. At 1937:36, the airplane was approximately 900 feet agl, and the pilot stated, "...we need to uh go around back in the pattern and come back in on uh either three five right or left please." At 1937:42, the controller stated, "...make a right turn make well you already your left turn keep keep un left turn and uh make left traffic for runway three five right." At 1937:53, the controller asked, "uh mitsubishi nine hundred uh are you do you require any assistance?" The pilot responded, "negative for right now uh just need to get in as soon as possible." At 1938:03, the controller stated, "o k say nature of the problem." At 1938:11, the pilot stated, "stand by one minute."

At 1938:31, the airplane was approximately 500 feet agl, and the pilot reported, "tower americheck nine hundred declaring emergency we've got an air an engine ta shut down uh please roll the equipment." At 1938:49, the controller cleared ACT 900 to land on runway 35R and stated the rescue/fire equipment was responding. At 1939:19, the controller requested from ACT 900 the souls on-board and fuel remaining. The airplane was approximately 400 feet agl, and the pilot responded, "two souls on board uh nineteen hundred pounds of fuel." At 1939:47, the controller stated, "americheck nine hundred you you can go ta two eight if you can do it." There was no response from ACT 900. At 1940:00, a transmission from an unknown source stated, "wind check". No further communications were received from ACT 900.

According to the controller-in-charge statement, "I saw ACT 900 turn base, overshoot final, and finally turn north. The aircraft lights made an abrupt nose down turn and the MU2 was gone." According to the local controller statement, "I cleared [pilot] to land on [runway] 35R. He overshot the base to final turn and went down east of the [runway]."

A witness, located in an airplane at APA who was monitoring the radio communications, reported he observed the airplane make the turn to base, "however, they shot through the final approach course, headed approximately due east." He stated the airplane was approximately 500 feet agl. While the airplane was on base leg, the witness observed the airplane continue to the east in a shallow descent with the left wing slightly low until it went out of the witness's sight. The witness stated he could tell the left wing was slightly low based on looking at the red position light and the rotating beacon.

Another witness, located in a vehicle traveling south on a nearby road, stated she observed the airplane at "less that 75 feet [agl], an average height, in my opinion, had the airplane been aligned with runway 35R to land. The airplane appeared to be flying on its side, as if to make a hard left turn. It then leveled out briefly, and I could see the bottom of the fuselage. Considering the darkness, I did not see the landing gear deployed... As the airplane passed my side window, I heard an aggressive throttle and the airplane make an immediate sharp bank to the left and descended to the ground. The airplane was descending as the speed increased. The impact appeared to be just less than a 45 degree angle, nose first." Approximately 5 minutes after the crash, rescue personnel arrived on the accident scene.

Another witness, located in a vehicle traveling north on the nearby road, stated he observed the airplane flying "very low". He stated, "just before impact, [the airplane] banked left and down."

Personnel information

The pilot, age 28, who was seated in the left front seat position, held an airline transport pilot certificate, issued June 24, 2002, with an airplane multi-engine land rating, and a private pilot certificate with an airplane single-engine land rating, issued September 10, 1996. The pilot's most recent FAA first-class airman medical certificate was issued on September 1, 2004, and contained a limitation for corrective lenses.

The pilot's logbook was used to document the pilot's flight experience. The pilot's total flight time at the time of the accident was 2,495.8 hours, with 1,864.2 hours in multi-engine airplanes. The pilot had accumulated 363.8 total hours in the accident airplane make and model, of which all were recorded as pilot-in-command. In the 90 days preceding the accident, the pilot had accumulated 206.5 total flight hours, all of which were in the accident airplane make and model; and 70.1 total hours in the 30 days preceding the accident.

According to the "Remarks, Procedures, Maneuvers, Endorsements" section in the pilot's logbook, one engine inoperative operations and other multi-engine maneuvers were recorded as having been conducted on October 15, 1998, on an undocumented date in 1998, and on March 3 and March 7, 1999. Both entries were recorded as having been conducted in a Piper PA-34-200 airplane. On February 5, 2003, the pilot recorded in the remarks section of the logbook, "Engine Failure", which was listed as occurring on a flight in a Piper PA-31-310. No additional one engine inoperative operations were documented.

In the logbook remarks section, on April 21, 2001, "Part 135 Checkride" in a Piper PA-31-350 was documented; on June 19 - 23, 2003, "Simuflite Training Level D Simulator" was documented; on June 28, 2002, "135 Check" in a Beech BE-200 was documented; and on January 29, 2003, "Check Ride" in a Piper PA-31-350 was documented. No check ride entries were documented in the logbook for the accident aircraft make and model.

On June 30, 2004, the pilot recorded the first entry in the logbook for a flight (APA to SLC) in the accident airplane make and model. No documentation was noted in the "Remarks, Procedures, Maneuvers, Endorsements" section of the pilot's logbook for the accident airplane make and model.

The operator provided the pilot's personnel records to the NTSB investigator-in-charge (IIC). A review of the records revealed the operator hired the pilot in January 2003. The pilot completed the operator's "initial new-hire" training in the Piper PA-31 model airplane on January 29, 2003. According to the flight training records, on the second of three training flights, the ins

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine powerTakeoff - initial climb
1 engine - stowed
Reason for occurrence undeterminedFactor
Loss of control - in flightApproach - vfr pattern - base leg/base to final
Airspeed(vmc) - not maintainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Aircraft

Registration
N538EA
Reported as
Mitsubishi MU-2B-60
Category
Airplane
Serial number
15385A
Airframe hours
12,665
Engine
Honeywell TPE331-10501M, 715 horsepower, turbo prop
Damage
Destroyed
Flight
Part 135
Registered owner
Flight Line Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · November 1, 2004 · 60 hours before
Departed
APA · Englewood, CO
Destination
SLC · Salt Lake City, UT
Flight plan
IFR
Airport
APA · Centennial Airport

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
28
Injuries
Fatal
Certificates
Airline transport, Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
July 12, 2004
Seat
Left
Toxicology
Performed
Flight hours
2,496 total · 364 in this make and model · 2,281 as pilot in command · 207 in the last 90 days · 70 in the last 30 days · 1 in the last 24 hours
Role
Co-pilot
Age
25
Injuries
Fatal
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Toxicology
Performed
Flight hours
857 total · 0 in this make and model

Weather

Conditions
Visual (VMC) · Night
Wind
270° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
48 °F, dew point 25 °F
Altimeter
30.25 inHg
Observed at
APA, 1 nm away

Docket · 52

The files NTSB released with the investigation on March 15, 2006, on NTSB’s docket system: statements, records, photos and specialists’ reports. 56.2 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 1.3 MBNTSB Performance StudyItem 2 · .PDF · 142 KBController StatementsItem 3 · .PDF · 119 KBWitness StatementsItem 4 · .PDF · 345 KBSatellite Image with Radar/Communications (MHIA)Item 5 · .PDF · 1.4 MBWreckage Diagram (MHIA)Item 6 · .PDF · 84 KBAPA Weather InformationItem 7 · .PDF · 37 KBATC Report and TranscriptItem 8 · .PDF · 156 KBExcerpt of Airframe ReportItem 9 · .PDF · 181 KBExcerpt of Honeywell ReportItem 10 · .PDF · 1.3 MBWoodward Left Fuel Control ReportItem 11 · .PDF · 121 KBWoodward Left Prop Governor ReportItem 12 · .PDF · 74 KBWoodward Right Fuel Control ReportItem 13 · .PDF · 93 KBWoodward Right Prop Governor ReportItem 14 · .PDF · 66 KBHartzell ReportItem 15 · .PDF · 340 KBExcerpts of Airframe RecordsItem 16 · .PDF · 253 KBExcerpts of Left Engine RecordsItem 17 · .PDF · 148 KBExcerpts of Left Prop RecordsItem 18 · .PDF · 98 KBExcerpts of Right Engine RecordsItem 19 · .PDF · 392 KBExcerpts of Right Prop RecordsItem 20 · .PDF · 62 KBPilot LogbookItem 21 · .PDF · 16.0 MBOperator's Pilot RecordsItem 22 · .PDF · 1.0 MBOperator's Pilot Record for PassengerItem 23 · .PDF · 36 KBExcerpts of Airplane Flight ManualItem 24 · .PDF · 108 KBMHIA Performance CalculationsItem 25 · .PDF · 28 KBCargo ManifestItem 26 · .PDF · 148 KBFuel ReceiptsItem 27 · .PDF · 150 KBExcerpts of Operator's Pilot Training ProgramItem 28 · .PDF · 860 KBStatement of Party Representatives to NTSB InvestigationItem 29 · .PDF · 57 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 30 · .PDF · 87 KBToxicological Report - PilotItem 31 · .PDF · 51 KBToxicological Report - PassengerItem 32 · .PDF · 48 KBView of Accident Site (NTSB)Item 33 · .PDF · 1.3 MBView of Main Wreckage (DCC)Item 34 · .PDF · 620 KBView of Main Wreckage (Honeywell)Item 35 · .PDF · 1.7 MBView of Main Wreckage (Honeywell)Item 36 · .PDF · 1.6 MBView of Main Wreckage (Honeywell)Item 37 · .PDF · 1.7 MBView of Empennage (Honeywell)Item 38 · .PDF · 1.7 MBView of Empennage (Honeywell)Item 39 · .PDF · 1.6 MBView of Ground Scar (Honeywell)Item 40 · .PDF · 1.8 MBView of Main Wreckage (Honeywell)Item 41 · .PDF · 1.8 MBView of Left Engine and Propeller (Honeywell)Item 42 · .PDF · 1.8 MBView of Right Engine (Honeywell)Item 43 · .PDF · 1.7 MBView of Right Engine (Honeywell)Item 44 · .PDF · 1.7 MBView of Cockpit (Honeywell)Item 45 · .PDF · 1.8 MBView of Pilot Instrument Panel (Honeywell)Item 46 · .PDF · 1.7 MBView of Cockpit Controls (DCC)Item 47 · .PDF · 691 KBLeft Engine Second-Stage Compressor Housing (Honeywell)Item 48 · .PDF · 811 KBLeft Engine Propeller Shaft (Honeywell)Item 49 · .PDF · 2.0 MBRight Engine First-Stage Compressor Impeller (Honeywell)Item 50 · .PDF · 1.4 MBRight Engine Second-Stage Compressor Impeller Shroud (Honeywell)Item 51 · .PDF · 2.6 MBLeft and Right Engine Oil Pump Transfer Tubes (Honeywell)Item 52 · .PDF · 804 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.